Breast Reconstruction

Breast Reconstruction

More than 211,000 women will learn that they have breast cancer this year.

When you are diagnosed with breast cancer, we understand that you may be overwhelmed by all the decisions you are expected to make all at once. Of highest importance is to control the cancer according to your medical, surgical, and radiation oncologists’ recommendations. Reconstruction is not any less important, but must not interfere with your cancer treatment. While it is easy to just go with what seems like the simplest and quickest option, we encourage you to take some time to learn more about your reconstructive options. If radiation therapy is not part of your initial treatment plan, your best opportunity for an optimal reconstruction is at the time of your cancer surgery, termed “immediate reconstruction.” Reconstruction that is performed after your cancer treatment has been completed is called “delayed reconstruction.” A well planned reconstruction at the outset, even in multiple stages, will minimize your need for future reoperations.

At your diagnosis, you probably had a biopsy, and now require either a lumpectomy or mastectomy. Even if you require chemotherapy after your initial surgery, immediate reconstruction is possible. However, if radiation therapy is part of your treatment plan, we recommend delayed reconstruction for the following reason. A tissue expander that is in place during radiation may interfere with accurate targeting of the lesion to be treated, due to the magnet inside the expander. In some instances, radiation oncologists have asked us to remove the tissue expander during radiation therapy. If a flap reconstruction is performed, the new healthy tissue that is brought in from elsewhere is now subjected to the same radiation beams that are targeting the cancer and cause damage. This damage manifests as thickening of the skin, called fibrosis, and eventual shrinkage of the flap. This is good for the cancer, but not for the reconstructed breast. As a result, further surgeries may be necessary to restore the size and contour of the reconstruction to match the other side. All forms of breast reconstruction can be performed in an immediate or delayed fashion.

Breast Reconstruction after Breast Conservation Therapy

Breast conservation therapy consists of lumpectomy, with or without radiation of the breast. The goal is to minimize the amount of breast tissue that needs to be removed. In situations where your breasts are uneven to start with, this may make you more even without any reconstruction! More likely, however, you will have a minor asymmetry that would require reconstruction. If it is simply a volume problem, fat can be transplanted from anywhere else on your body, or an implant inserted if the volume is significant. The nipple position can be affected, however, in which case proper replacement of tissue with your own (autologous) tissue, called a flap, may be necessary to address both problems. Please refer to the later discussion on flaps for more information.

Breast Reconstruction after Mastectomy

Tissue Expander/Implant Reconstruction

When your breast is removed at the time of the mastectomy, the overlying skin can be preserved in what is called a “skin sparing mastectomy.” This is the preferred method when undergoing immediate breast reconstruction to preserve as much soft tissue cover as possible. Your surgeon only goes as deep as your pectoralis major muscle. This muscle provides the perfect covering for a future implant, the same kind that is used in cosmetic breast surgery. Because the tissues require some time to adequately stretch without harming their blood supply, a tissue expander is inserted initially rather than an implant to allow the stretching to occur over a period of a few months. The tissue expander is a shaped device with a magnetic port that we can access through your skin in the office to fill every two weeks. Once you reach a desired size, we choose the best sized implant for you and insert that implant at a second stage procedure six months from the time of your initial surgery. The final and third stage of the procedure involves nipple and areola reconstruction, which will be discussed later. Except for the first procedure, which requires an overnight stay due to the mastectomy, the subsequent stages are performed as outpatient surgeries with downtime of only a couple weeks each.

The main limitation with this method of reconstruction is the maximal size achievable and the risks of capsular contracture. Capsular contracture occurs when your body builds up too much scar tissue around the implant as it attempts to protect itself from the “foreign body.” This is not a preferred method of reconstruction if you have had radiation because your body will be more prone to capsular contracture due to the radiation injury.

Latissimus Flap Reconstruction

Spanning the length and width of each side of your back is your latissimus muscle, which is used for rowing, skiing, and reaching down from overhead. This muscle can be rearranged to provide soft tissue and skin with a robust blood supply to create a natural shaped breast. Unless you are a professional swimmer or skier, most patients compensate for the loss of this muscle without realizing it is gone. This surgery is performed in stages as well, and can be done on both sides at the same time.

At the initial surgery, the muscle flaps are borrowed from your back, leaving a scar along the natural skin lines of the back. The scar can be left along the bra line, but because it does not follow the natural skin lines, the scar that results is usually widened and aesthetically inferior to the other option. The flap is then buried in your armpit and brought out in the front to contour into a breast. Most patients require more volume than is provided for by the latissimus flap, so a tissue expander is placed at the same time. Sometimes the nipple and areolar reconstruction can be performed at this first stage. Drains are left in place in the breast as well as the back. The back drain may stay as long as 4 weeks. We encourage physical therapy during this time to reeducate your lymphatics to drain properly and minimize the drainage into the drains. Recovery from this surgery can take six weeks. The initial hospital stay is usually two days.

Once you have healed over the next six months and fluid added to the tissue expander, the second stage involves exchange of the expander for the implant and any other revisions necessary. If the nipple and areola have not yet been reconstructed, they are attended to at a third stage procedure.

TRAM Flap Reconstruction

This method of breast reconstruction is what most women refer to as the tummy tuck operation. Indeed, this procedure is very similar to the cosmetic tummy tuck procedure, where an ellipse of excess skin from the belly is removed. The difference is that the tissue that is removed in reconstruction remains attached to the underlying rectus muscle to provide blood supply, thus called the Transverse Rectus Abdominis Muscle flap. This tissue is then rotated upwards onto the chest to contour into a breast. It is very rare to use an implant in conjunction with this flap.

While this method provides a great bonus of a tummy tuck, it involves more risk than the latissimus flap. If you have heart disease, diabetes, or currently smoke, this procedure is not for you. Your blood vessels are even more sensitive to any changes in blood flow, making the TRAM flap risky. The reason why is that the blood supply to this flap runs through a more torturous route of vessels than that of the latissimus flap. In most patients, there is a dominant channel within the nest of vessels that provides reliable blood flow. In approximately one-tenth of patients, however, there is no dominant channel on which the flap can rely. Sometimes, keeping both rectus muscles attached to the skin flap will remedy this problem. This anatomic phenomenon affects the feasibility of the microsurgical DIEP technique as well, to be mentioned later. Both rectus muscles can be used to reconstruct two breasts at the same time as well. The main risk of this is the development of weakening of the abdominal wall.

Recovery from this surgery takes at least six weeks, as you learn how to transfer from a sitting to standing position without your rectus muscle. The hospital stay is typically 3-5 days. You will have two drains in the abdomen and one for each breast. The second stage procedure occurs after six months as well. At this stage, the nipple and areola are reconstructed and any necessary revisions made.

Microsurgical Breast Reconstruction

Microsurgery has revolutionized the field of plastic surgery by opening up a whole new realm of possible donor sites. The breast can thus be reconstructed not just from the the back or TRAM flap, but also the buttocks via the superior gluteal artery flap or portions of the abdomen via the deep inferior epigastric artery or superficial inferior epigastric artery flaps. This type of reconstruction involves the complete removal of the donor site tissue from your body and reattachment of blood vessels using the microscope into the desired location. For the breast, this usually involves removal of part of your rib to access a recipient blood vessel to be attached to the flap. Once the tissue has been successfully attached, the contouring of the breast is performed the same way as in the latissimus and TRAM flaps described above.

With this added sophistication comes added risk as well. The time required under anesthesia can be as long as 12 hours, and hospitalization is typically 5-7 days. Intensive care monitoring of the flaps, a hot room, and blood thinning are required in the first few days of surgery. If there is any question about the survival of the flap within the first week, you must return to surgery immediately. The benefit of these procedures, however, is that less tissue needs to be removed from the donor site, thereby minimizing such risks as abdominal weakening. In some patients who have had previous surgeries or even breast reconstruction, the microsurgical techniques may be the only option left available to them.

Nipple and Areola Reconstruction

The final stage of breast reconstruction with any technique is the creation of a nipple and areola. The areola is the colored circle that surrounds the nipple. The nipple is usually reconstructed by rearranging the local tissue from the breast, in the case of implant reconstruction, or rearranging the tissue of the back or abdomen, in the case of flap reconstruction. Nipples reconstructed from the thicker tissue of the back tend to maintain their projection much better than the soft tissue of the breast and abdomen. The areolae are typically recreated by a skin graft either from the groins or from a previous scar. While we have been successful in reconstructing the structure of the nipple and areola, we are not able to restore sensation to the nipple due to the removal of the breast tissue and nerves.

This stage of reconstruction can often be done under local anesthesia if not being done at the time of an implant exchange or revision. Once the wounds have healed, tattooing of the reconstruction to match your skin tone completes the reconstructive process. All said and done, the breast reconstruction process will take nearly one year. It is not uncommon for patients to forgo this part of the reconstruction, as they are ready to move on with their lives.